How to Code for Claviculectomy

- Published on Mon, Nov 01, 1999

Shoulder pain associated with adduction activitiese.g., golf swing, carrying a heavy tray above the shoulder with one handoften indicates a problem with a clavicle. Acromioclavicular (AC) joint arthritis is such a problem, and a common one.

But there are other problems as well. For example, a fall that pushes the scapula down causes it to tear the AC ligament and displace the clavicle. Or the clavicle might be deformed as a consequence of radiation therapy administered to treat childhood cancers (a well-known side effect).

Removal of the distal clavicle (partial claviculectomy) brings pain relief to many patients, particularly those with osteoarthritis. The excision of one-half inch or less of the distal clavicle encourages the development of scar tissue. And that tissue takes on the role of a (false) joint.

Distinguishing Between Open and Closed Approach

Partial claviculectomy, also known as distal clavicle resection, can be accomplished through open or arthroscopic procedures. The open procedure requires an incision of at least two inches.

The CPT code for partial claviculectomy is 23120 (claviculectomy; partial). But the code only applies to an open procedure.

If the surgery is done with a scope procedure, it must be a 29909 (unspecified procedure, arthroscopy), cautions Susan Callaway-Stradley, CPC, CCSP-P, an independent coding consultant who was recently named the American Association of Professional Coders coder of the year. And the steps must be described.

One such arthroscopic procedure is known as the Mumford, which uses three standard portals. It includes six steps.

Sandra A. Thomas, a coding and billing consultant based in Houston, TX, echoes Callaway-Stradleys recommendation. Moreover, she says, The 23120 only applies if other measures are not part of the surgery. If there is a more radical procedure [cf. below], another code [will apply]. And if a 29909 is used, the operative report must be included.

Supporting the CPT

The CPT must be supported by an appropriate diagnosis code. For example, for osteoarthritis at the AC joint, 715.31 (osteoarthrosis, localized, shoulder region) can support the claviculectomy procedure.

If the procedure is unilateral, indicate it with an -LT (left side) or -RT (right side) modifier. And if it is bilateral, use the -50 modifier.

Proper coding aside, a harsh surprise awaits claimants who file for reimbursement for a bilateral partial claviculectomy. Medicare C will not reimburse extra for the bilateral procedure, says Callaway-Stradley. It will reimburse at 150 percent for a bilateral total claviculectomy. But a bilateral partial is paid at the same amount as a partial on one side.

Most commercial payers follow the lead of Medicare C, so this is a loss for most claimants.